Time for honest reflection, not defence

The closure of the Gender Identity Development Service (GIDS) at the Tavistock has attracted significant public and media attention.

Closure resulted from the Cass Review of children and young people's gender services in England. The interim report recommended a new service model which acknowledges multiple routes in and out of gender dysphoria. Elevated rates of same-sex attraction, autism spectrum disorders, mental health issues, and looked after children were noted amongst the – now majority female and hugely increased – GIDS cohort. Dr Cass reported that 'diagnostic overshadowing', using gender as the primary clinical lens, had led to such wider issues being relatively neglected. Inadequate records and data were highlighted, particularly regarding puberty blocker outcomes. The new model intends to re-centre the young person's needs, taking a holistic view of their difficulties.

These constitute serious criticisms of a flagship psychology-led service, resulting in its closure to protect patient safety. In this context, the statement issued by the BPS is profoundly inadequate. It offers no acknowledgement of the severity and range of these problems, or of the harm done to some children and young people. There is no reflection on mistakes made or lessons to be learnt.

Defence, not reflection, has been a theme throughout the story of GIDS. Many clinicians, parents and patients have raised repeated concerns about the practice model. Ex-patients have discussed feeling rushed into body-altering interventions which some have come to regret. Criticism has grown louder recently, following a 2018 internal report, a judicial review in 2020, damages awarded to the Trust safeguarding lead and an 'inadequate' CQC report in 2021, plus increasing media coverage. Concerns that GIDS was operating outside usual clinical practice were first raised, however, in 2004. Critics have consistently been labelled bigots or transphobes and ostracised.

This is a sobering moment for psychology. We need to take seriously that damaging practice was enabled for so long. Hundreds of psychologists worked at GIDS – highly trained scientist-practitioners skilled in reflective practice. Hundreds more have watched this unfold from the outside. Why did it take an external review to address the widely aired problems? Why was the service not able to reflect and change itself, instead vilifying critical voices? These are questions that psychologists should be well placed to answer, as experts in human meaning-making, embodied distress and group processes. We know that as a profession we are fallible, because we know that mistakes are made by all humans and all groups – yes, even by 'me'.

We also know about recovery and redemption. Difficult things can be tolerated, made sense of and moved beyond. First, we need to acknowledge what has happened and the risks that have been taken with young lives. Some children have been badly let down and may not be forgiving. Nor should they have to be. Trust in psychology has been damaged by this episode and our collective failure to address the emerging scandal. Rebuilding trust requires accountability, honesty and reflection. We must not retreat into the comfort of defensive denial at this crucial moment.

• Dr Laura McGrath, Lecturer in Psychosocial Mental Health
• Dr Anna Hutchinson, Clinical Psychologist
• Dr Sallie Baxendale, Consultant Neuropsychologist
• Dr Libby Nugent, Clinical Psychologist and group work practitioner of group analysis
• Dr Kirsty Entwhistle, Clinical Psychologist
• Amanda Perl, Existential Psychotherapist, former Lecturer in Forensic Psychology and Counselling
• Dr Jenny Paton, Consultant Clinical Psychologist
• Dr Celia Sadie, Consultant Clinical Psychologist
• Dr Lauren Quigley, Clinical Psychologist
• Dr Russel Ayling, Clinical Psychologist, Psychoanalytic Psychotherapist
• Dimitri Spiliotis, Counselling Psychologist
• Anastassis Spiliadis, Systemic & Family Psychotherapist, MSc Psychology
• Dr Jenny McGillion, Clinical Psychologist
• Dr John Higgon, Clinical Neuropsychologist

Editor's response

I agree that this is a moment for 'sobering' 'reflection'. I note that the BPS statement said 'We will carefully review the new proposals as more detail becomes available and will respond to the planned consultation on the new service.' It's also interesting to see the Tavistock and Portman NHS Foundation Trust statement, with its admission that the 'level of need cannot and should not be met by a single highly specialist national service'.

In terms of our own coverage, we are a forum for discussion and debate and we are keen to hear from a range of voices, including trans people and those psychologists who work directly with them. Please reach out on [email protected].

We will begin to publish a selection of responses here:

Why did this 'scandal' happen in the first place?

As a trans person waiting to be seen by the UK adult services, and as someone who has watched the media-led moral panic about trans people (and trans young people in particular) unfold over the last five years, I read the letter 'Time for honest reflection, not defence' with both interest and some trepidation. As expected, the trepidation was well-founded.

The letter talks at length about trust and failure, and the need for honesty, but it falls at the first hurdle. The authors themselves point out that critics of GIDS have consistently been labelled bigots or transphobes. However, I would encourage readers to seek out their public and social media statements on trans issues, and those of groups and individuals that they follow, to assess whether they are inclusive of trans voices and experiences, and subsequently whether their views here represent anything more than a veneer of faux concern.

The letter itself is replete with distortions and misinformation, linking trans-hostile articles, actors and activists throughout, as well as propagating well-known trans-hostile talking points, pushing the current moral panic narrative prevalent in the media, and it even misrepresents the closure of GIDS, failing to even mention that the service is being replaced by regional and local services with the intent of improving accessibility and treatment. 

It does little more than present a single side of a highly complex area of psychology as the only 'correct' view, ignoring the lived experiences of tens of thousands of trans people who lead much happier lives because of the treatment they fought to access.

But why did this 'scandal' happen in the first place? 

Parents, service users and trans people have been raising the alarm on this for more years than the trans hostile activists who are touting this as some sort of victory, but as usual, trans people are ignored. 

We are ignored because GIDS, the wider NHS Mental Health Services, and frankly the so-called professional bodies who monitor practitioners, all refused, and continue to refuse, to listen to us. Gender services are no exception in this regard. It's a problem prevalent across the entire scope of the relevant professions, where clinicians' personal biases and opinions ride roughshod over trans people's lives.

I speak from personal experience. In trying to access a diagnosis for ADHD as an adult I was repeatedly told by 'professionals' that my experiences were due to 'being trans' – despite said professionals also stating they knew nothing about 'being trans'. Unsurprisingly after a two year fight, I was diagnosed with ADHD. A small example of the issues trans people face: one that's emblematic and repeated ad infinitum across services.

Mental Health practitioners have a major problem when it comes to being trusted by trans people, and this letter is a prime example of why that lack of trust will remain until the professional bodies clean their house of known conversion abuse practitioners and those practicing in this field who are oppositional to trans people. Until that happens, and until the professionals overcome their 'we know you better than you do' attitudes, this lack of credibility and trust will remain unresolved.

The World Health Organisation removed Gender Incongruence from the mental health category of the International Classification of Diseases in 2019. In the 1950's transgender people were treated successfully under the auspices of endocrinology, but that changed in the 1960's when those fledgling services were taken over by mental health 'professionals', ushering in an era of conversion abuse that continues in various forms today. 

While UK mental health practitioners can be vital in a supportive role in dealing with issues unrelated to gender incongruence, it's high time they were removed from gatekeeping access to treatment in the UK, because you cannot 'diagnose' a person's identity and not have a detrimental impact on trans lives.

Claire Prosho

Claire's Transgender Talks: www.clairestranstalks.co.uk

'Those of us still trying to find our way through…'

So, child GIDS is to be closed. The reactions are, perhaps predictably, polarised. From "damning indictment" to the brave face of "simply a regional relocation". The Cass report is, to my eye, far more nuanced than these verdicts (though the criticism is inescapable). It's an emotional moment personally.

There was a time when I was a significant supporter and felt it offered what young people needed. But much has changed and it's been a long time since I felt that. I can't quite pinpoint when things started to shift, but being the parent of a trans child (and a family member of a GIDS service user) is undeniably part of it.  

Approaching the Tavi (as everyone calls it and I will here) I think I held an expectation that they would offer an approach that engaged with the complexity of my own feelings. This was a big thing we were talking about: not just a change or role but life-changing and irreversible physical treatments. It would surely be, in their own words, "thoughtful'. And I suppose it was, to a degree. But maybe not quite as much so as I expected.

Or perhaps as much as I wanted. To be fair, I also wondered how much room the staff had to be searching. Could they hold the gates to physical treatment shut? After all, by the time kids arrived in Belsize Park many, it seemed, had just one intention: to get to the meds. The possibility of alternatives, questions or challenges all felt a long time ago.

Above all there was little chance to think about the social pressure (not coming from the Tavi I hasten to add), "your kid will kill themselves if you don't get on board". Those of us who resisted hormone blockers felt we were walking a lonely, and risky, path. I was lucky, I think. I have a child who didn't push this choice too hard.

I know others for whom the pressure has been almost unbearable. The difficult thing for many parents was that the Tavi, whatever we hoped, was never designed for us to be the primary focus. They did try. There were parental support groups and regional outreach. But the GIDs clinic has been resourced with the aim of supporting young people. Obviously there are different views on how that responsibility was held. 

One thing that strikes me again and again is how, in our gender-fluid world, parents and loved ones are either simplistic stereotypes, or just invisible. Parents especially, are usually portrayed as either angry-rejecting or warm-supportive. More pejoratively, warm-supportive has been characterised as in cahoots with charities to pressure services into doling out the drugs. 

And for yet so many parents (and others) I've encountered on this journey, the experience is so much more complicated and painful. They're not kicking their child out or seeking a divorce. They're trying hard to be on board with something that, in the privacy of their hearts, they feel is not quite real.

Trying to support bodily changes that break their hearts. You can't say it of course. Feeling that way means you're a transphobe. And so, invisible we remain. So many are still really trying though. You can't, we are told, have LGB without the T. All progressives should get on board. But this feels so fundamentally different from coming out as lesbian or gay. In almost every way I can imagine. 

In the end the Tavi was never, perhaps could never, be something that was truly able to support families experiencing these kinds of pressures. The Cass Report at least has aspirations to address this. The focus is, perhaps rightly, still mainly on young people though. But I hope services and psychologists can still do something for those of us still trying to find our way through. For that I have a suggestion. It's simply this. Don't forget we are there too.

There is more than one group of people who need to be helped and included. When you're making sure you have your pronouns declarations right, and an apology for accidental misgendering ready to go, think about it for a minute. How might your keen support go down with someone who may feel like they have lost a daughter, or a son, or a father, or a wife. The Tavi couldn't be there with us. With a little care you can be.

Name and address supplied

'Whose trust we ought to seek…'

Trust and credibility go the heart of the matters raised in the letter 'Time for honest reflection, not defence'. The authors note that the reputation of psychology is on the line and that rebuilding trust will require accountability, honesty, and reflection. In this respect, they're not wrong.

However, because the authors do not grapple with whose trust we ought to seek, their analysis comes across, ironically, as defensive – as scrambling to protect the profession's image from scandal in the eyes of the wider public, rather than listening to the voices of LGBTQ people, who are most affected by the issues discussed.

For instance, the letter fails to acknowledge that psychology has already been historically enmeshed in efforts to pathologise diversity in gender and sexuality, and that this itself is reason enough for the LGBTQ community to harbour distrust, anger even, toward psychology and other clinical professions. Although the situation is arguably better in certain respects today (thanks in part to professional bodies taking a stand), LGBTQ clients (and even clinicians) continue to have experiences that compound that distrust, ranging from derogatory comments to full-fledged conversion attempts.

Starting from this point would have led the authors to consider the experiences of those who are trans and gender diverse and their struggles navigating systems putatively set up for their care, particularly in the midst of a hostile sociopolitical climate where their very existence is treated as a matter of public 'debate'.

By not focusing on their voices, and by not acknowledging psychology's historical role in legitimating pathological narratives about LGBTQ life, the letter's call for 'rebuilding trust' comes across as disingenuous at best. The way the letter was immediately seized upon and promoted by some should also be regarded as a moment for honest reflection – who is this letter helping and, again, whose trust are we seeking to regain?

Address supplied

'We can find common ground'

As a charity focusing on research and information relating to transgender and gender diversity topics, we welcome the replacement of GIDS with a network of regional centres – and in particular, the call for embedded research and training.

Much of the media discussion about the closure of the Gender Identity Development Service (GIDS) has been sensationalist nonsense. We are disappointed to see some psychology professionals also misrepresenting the reasoning, impact, and benefits of this development. We are concerned about the premise of the joint letter: it seems to be hinting at the false idea that Cass has found medical transition to be harmful to children and young people, although seems to stop short of saying so.

GIDS itself has received significant criticism: young trans people and parents have described it as a service that restricts access to care, rather than providing support. The CQC described it as "inadequate", and that its safety "requires improvement". The waiting list has grown to an unsafe level. The Cass letter described that the current model – of a single provider – is unsustainable, and that the service design had insufficient quality controls. Rather than the media's suggestion that the clinic was dishing out adult hormones like sweets, the reality is very different: it lacked good record-keeping, did not have consistent use of structured care plans, and was treating too few people.

The joint letter misrepresents Cass, suggesting "multiple routes in and out of gender dysphoria" should be a focus of the new service design. We must be extremely cautious about the framing of "routes out of gender dysphoria", which could be taken as advocating conversion therapy.

The authors bring up to "same-sex attraction, ASD, mental health" but do not tackle how these factors are  often used to dismiss the experiences of gender-diverse children and young people, and do not justify failure to support them. Cass mentions "diagnostic overshadowing", which does indeed compromise care: gender diversity is dismissed as "autistic obsession"; patients are bounced around CAMHS instead of referred correctly. At the other end of the spectrum, "trans broken arm syndrome" is a phenomenon that trans people are all too familiar with.

 The real Cass recommendations are – as they should be – about a holistic model of health, where additional services can be called upon wherever the need for them arises. The focus must be on support.

We agree with Cass that this must mean affirmative clinical support: not the straw-man misreprestentation of "affirmative care" that supposedly excludes patient history, exploration, and somehow pushes children down an inevitable path to surgery, and not "watchful waiting" that denies a young person their own selfhood and can force them through the traumatic and irreversible experience of going through the wrong puberty for them. We support her call for more research – however, this need for improved evidence to support care must not be used as an excuse for denying the best possible standard of care based on the evidence we have in the meantime.

Regardless of intent, we can find common ground with the authors: "this is a sobering moment for psychology. We need to take seriously that damaging practice was enabled for so long." As Cass says, many trans people consider clinicians to be "gatekeeping" access to medical treatment. We suggest that a great many trans people have lost trust in psychology because of their experiences of cisnormative services that pathologise trans and gender-diverse people. Services must be co-designed with trans people, and not imposed upon us: this is an imperative, both for building trust and to ensure services are truly reflective of trans and gender diversity needs.

Finally, to make our own position plain: we already have medical consensus that gender incongruence is not a mental disorder. We must next abolish the idea promoted from some quarters that transition is a negative outcome.

Dr Harriet Hutchinson
General Manager, GIRES

Reubs J Walsh,
Trustee, GIRES, and Junior Fellow, Center for Applied Trans Studies

GIRES (www.gires.org.uk) is the leading UK charity promoting research and education on trans and gender diversity issues.